Pouncey Tract Veterinary Hospital

25026 Ferndale Rd, North Dinwiddie, VA, 23803

Phone: (804) 732 - 6420 Fax: (804) 861 - 6940 Email: frontdesk@chesdinah.com
- Where should we send this prescription order?
- Prescriber
- Prescriber: Please Fill In Name
  
  First NameLast Name
- Person Placing this Prescription Order:
  
  First NameLast Name
- Pet's Name
- Species
- Owner's Name
  
  First NameLast Name
- Owner's Cell Phone Number
  Please enter a valid cell phone number for text messages from the pharmacy.Format: (000) 000-0000.
- Owner's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Owner's Date of Birth
  
  MonthDayYear
  Date
- Drug
- Manually Enter Drug Here
- Drug Form
- Other: Drug and Strength
- Chews Drug Strength: mg
- Suspension Drug Strength: mg/mL
- Transdermal Gel Drug Strength: mg/0.1mL
- Capsule Drug Strength: mg
- Drug Quantity
- Drug Flavor
- Instructions:
- Number of Refills
- Due to new animal compounding documentation requirements from the FDA, please select one of the options below.
- Reasons to compound:
- Notes and Special Instructions
- Signature
- Should be Empty:

25026 Ferndale Rd, North Dinwiddie, VA, 23803